Unmet needs for rehabilitation service of middle-aged and older adult residents in Chengdu, Sichuan, China: A cross-sectional study

To investigate the unmet needs for rehabilitation services among middle-aged and older adults in Chengdu, Sichuan, China, and identify the associated factors. This cross-sectional study was conducted on middle-aged and older adults in Chengdu, Sichuan, China, between 2015 and 2016. The questionnaire included demographic data and questions about rehabilitation needs. Multivariable logistic regression analysis was used to identify the associated factors of unmet needs for rehabilitation services. Among 663 participants, 91.70% needed medical rehabilitation (608/663), 26.55% of who need auxiliary equipment (176/663), 77.07% of who need daily care and social participation (511/663), and 79.34% of who need recreational therapy activities (526/663), while < 30% required auxiliary equipment. Multivariate logistic regression analysis showed that residents who were married, had annual income < CNY 80,000, had no medical insurance, had three or more health problems, were aged ≥ 60, and the disability status were independently associated with unmet needs for rehabilitation services (all P < 0.05). Marital status, annual income, medical insurance, health problems, and disability might be factors independently associated with the unmet needs for rehabilitation services. Attention should be paid to the financial burden of the population on rehabilitation services, and in addition to the disabled, the slow patients should also be given priority.

www.nature.com/scientificreports/ Canada, reporting that their needs for rehabilitation services were not effectively met 11 . These population-based studies are lacking in China, particularly those focusing on middle-aged or older adults. Previous research has mainly focused on community groups with particular needs for rehabilitation services. For example, a study on the need for rehabilitation services among people with disabilities being discharged from hospitals in Poland revealed that orthopedic equipment and home renovation service did not sufficiently meet their needs 12 . Previous studies identified financial factors that could predict the use of rehabilitation resources, including physical dependence, major illness, time spent in medical care, having a family physician, having illnesses, age, and intact cognitive functions 13,14 . No similar study on rehabilitation needs in Mainland China has been conducted.
Therefore, this study investigated the need for rehabilitation services among all middle-aged and older adults in three Qingyang District communities in western Chengdu, the capital city of Sichuan Province, as well as the factors associated with the unmet needs for rehabilitation.

Methods
Study design and participants. This cross-sectional study investigated the unmet needs for rehabilitation services among middle-aged and older adults in three Chinese communities in Qingyang District, Chengdu, Sichuan, China, between 2015 and 2016. The inclusion criteria were (1) adults > 45 years with good cognitive ability, (2) permanent residents of Qingyang District, Chengdu, or outpatients, and (3) people with some need for rehabilitation. The exclusion criteria were (1) acute illnesses or (2) an incomplete questionnaire. This research was approved by The Chengfei Hospital Ethical Review Board (Approval number: 2014009; 1 September 2014). Written informed consent was obtained from all participants. All methods were carried out in accordance with relevant guidelines and regulations. All procedures were performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.
Procedures. This study was based on a survey administered using a structured interview. The potential respondents were sent invitations in advance, saying that the investigators would contact them and that they were free to participate or not. Then, within 1 month of the invitation, the investigators met the respondents, obtained written informed consent, conducted the face-to-face interview, and filled in the interview table.
The determination procedures of the cognitive abilities of the participants were as follows. (1) Confirm whether participants had clear consciousness. The Glasgow Coma Scale (GCS) was used to determine the degree of consciousness disorder. Clear consciousness of the participants was a prerequisite for cognitive function assessment. (2) Screening for cognitive dysfunction. Under the condition of clear consciousness, the participants were screened for cognitive dysfunction using the Brief Psychiatric State Examination Scale (MMSE) and Cognitive Ability Examination Scale (CCSE), which is a key step in the assessment of cognitive dysfunction. The two scales are currently equally effective, and all participants completed both scales [15][16][17][18][19][20][21][22] . In the MMSE, a score < 24 is considered cognitive impairment 23 . In the CCSE, a score < 27 was considered cognitive impairment 24 . As long as a score on one of the scales meets cognitive dysfunction, it is considered cognitive dysfunction. (3) Those with intellectual disabilities were excluded from the sample according to the statistical principle of full consideration of the population sample.
Sampling and sample size. At the end of 2014, the three communities had 69,771 residents, 10,933 of whom were > 45 years old. For sampling, this study assumed a response rate based on the usual response rate of questionnaire surveys in China, about 50% 25 , and sampled twice as many residents as necessary for stable statistical analysis. Thus, 820 residents were sampled using the simple random sampling (preliminary survey) and systematic sampling (formal survey) methods with SPSS. The respondents were randomly selected from the official residency lists.
Questionnaire survey. In this study, the "need for rehabilitation" refers to any need that an individual with a health condition may have that requires rehabilitation management, interventions, and/or the use of specialized rehabilitation services or programs 26 . The "unmet needs for rehabilitation" that individuals might experience refer to any needs for rehabilitation services identified by a healthcare provider that the individual is unable to get due to different barriers 26 .
The City Rehabilitation Service Needs Questionnaire (CRNQ) includes questions about residents' characteristics and rehabilitation needs. Appendix 1 presents the details of the CRNQ. Trained researchers, most of whom were professionals in rehabilitation medicine, were trained to administer the CRNQ. The first part of the CRNQ includes questions on the respondent's demographic characteristics, health status, activity level, financial status, and social security characteristics. Disability was measured using the disability assessment questions of the Chinese Ministry of Health Rehabilitation Medicine teaching materials. Health status was measured using the first edition of the questionnaire on community rehabilitation needs for community rehabilitation science of the Ministry of Education of the People's Republic of China and the National Health Commission of the People's Republic of China. The second part of the CRNQ focuses on unmet needs for rehabilitation service, defined as "a service or a resource that would confer a health or rehabilitation gain" 27 , including medical rehabilitation, auxiliary equipment, daily care, social participation, and recreational therapy activities. At the end of the CRNQ, the respondents were asked to list all their unmet needs for rehabilitation services in order of importance.
A pilot study was conducted to ensure the questionnaire's validity and reliability. A total of 30 middle-aged and older adults participated in the study. Based on discussions with the middle-aged and older adults who participated in the pilot study, categories were developed to help respondents understand the definitions of rehabilitation medicine and the need for rehabilitation services. After the preliminary survey, categories were www.nature.com/scientificreports/ developed to help respondents understand the definition of rehabilitation medicine and the need for rehabilitation services. During the questionnaire development process, the unclearness of the description was found for the questions of "family income" and "whether there is an elevator in the building" through the pre-survey, and then the questionnaire was revised after discussion with the expert group. Five experts in neurology, disability, public health, and rehabilitation medicine reviewed and approved the items. The experts found correlations between "service cost", "home environment", and "rehabilitation needs according to the research on rehabilitation needs" according to the following viewpoints. The unaffordability of the services, especially in low-income countries, represents an additional barrier for people in need of rehabilitation 26 . In addition, living in a residential home means better adjustment to the living environment and better provision of orthopedic and rehabilitation equipment 28 . Regarding reliability, the data used in the analysis were tested, and Cronbach's reliability coefficient α was 0.92 for the sample (n = 663). The response rate was 80.8%.
Disability. The definition of disability in the teaching materials of Rehabilitation Medicine of the Ministry of Health of China is "Disability refers to obvious physical and mental dysfunction caused by trauma, disease, developmental defects, or mental factors, affecting the ability to live, work, and learn normally to varying degrees. Disability in a broad sense includes sickness and disability, which is a general term for physical and mental dysfunction of the human body" 29 . The disability certificate from the Ministry of Civil Affairs was required to be provided by the respondents.
Statistical analysis. SPSS version 23.0 software (IBM, Armonk, NY, USA) was used for statistical analysis.
Chi-square for contingency or Fisher's exact test was used for the categorical variables. Multivariable logistic regression analysis was used to estimate the odds ratios (ORs) and 95% confidence intervals (95% CI) of the relationships between independent variables and the perception of unmet needs for rehabilitation services. Only the statistically significant independent variables in the bivariable analysis were included in the multivariate regression model, and variables lost the significance in the multivariate analysis and were excluded from the final model and not shown. All P < 0.05 was considered statistical significance.
Ethics approval. This research was approved by The Chengfei Hospital Ethical Review Board (Approval number: 2014009; 1 September 2014). Written informed consent was obtained from all participants. All methods were carried out in accordance with relevant guidelines and regulations. All procedures were performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.

Results
There were 157 residents excluded: 145 did not complete the questionnaire (59 did not want to disclose their marital status, 72 did not want to disclose their financial status, and 14 did not want to disclose their health insurance), six had an acute stroke, and six reported no need for rehabilitation (Appendix 1). Therefore, the final sample consisted of 663 respondents, including 279 males and 384 females. There were 72.9% of respondents aged ≥ 60 years or older, 92.3% were married, 79.8% were without a college degree, and 67.4% reported annual income < CNY 80,000 per year. Regarding health, 90.3% had healthcare insurance, 1.7% reported disabilities, and 72.4% reported one or fewer health problems (Table 1). Furthermore, regarding the unmet needs, the results showed that 91.70% (608/663) of the respondents had unmet needs for rehabilitation service, 26.55% (176/663) needed auxiliary equipment, 77.07% (511/663) needed daily care and social participation, and 79.34% (526/663) needed recreational therapy activities ( Table 2).

Discussion
The present study showed that respondents who were married, had low income, or had health problems were more likely to report unmet needs for medical rehabilitation. Furthermore, having no medical insurance was associated with a higher possibility of reporting unmet medical and recreational rehabilitation needs. Importantly, the respondents aged ≥ 60 years old, particularly those who reported disability, had a significantly higher possibility of indicating unmet needs for auxiliary equipment.
These results are consistent with previous studies from other countries that reported how marital status influenced rehabilitation needs. In Sweden, the dyads, i.e., the social arrangement of two persons involved in an ongoing relationship or interaction, were found to influence rehabilitation service needs 30 . The study from Sweden revealed that patients' caregivers estimated that the needs of those involved in an ongoing relationship or interaction 12 months after stroke were more likely to be met 30 . Another study found that marriage was related to a higher demand for medical rehabilitation 31 . The current study revealed that being married was associated with a higher possibility of reporting unmet medical rehabilitation needs, which contradicts Kołłątaj's results in Poland 32 that showed how the needs for rehabilitation services of unmarried individuals were relatively difficult to satisfy. With shorter hospital stays and more care and rehabilitation being delivered at home, the patient's www.nature.com/scientificreports/ families and friends are likely to be more involved and have increased responsibilities for informal care and rehabilitation after, for example, a stroke. Studies showed that the people with whom someone shares their everyday life have an important role in the rehabilitation, and these people can prompt and urge the patients to seek rehabilitation [33][34][35][36] . Therefore, further research is needed to clarify the influences of marital status on the perception of rehabilitation service needs. The relationship between income and rehabilitation service needs might be related to peoples' decisions and ability to pay for service. People with little disposable income might hesitate to use costly services, delaying recovery or social integration after an illness. Consequently, the optimal period for recovery might pass without the provision of adequate intervention in rehabilitation, and some disabilities might become irreversible, thus further posing a burden on society 13 . According to Mitsch et al. 32 , rehabilitation after brain injury in Australia was associated with higher transportation and housing costs, putting a financial strain on family members and rehabilitation service providers. Hence, there is a relationship between medical service expenditures and rehabilitation service needs 32 . Yet, the previous studies mostly focused on people with particular disabilities, leaving a gap this study sought to overcome.
Several previous studies identified financial factors that could predict the use of rehabilitation resources 13,14 . The financial factors include the costs of the rehabilitation services corresponding to the family's economic level. Kamenov et al. 26 found that the unaffordability of the services, especially in low-income countries, represents an additional barrier for people in need of rehabilitation. The current study found that respondents without health www.nature.com/scientificreports/ www.nature.com/scientificreports/ insurance had more unmet rehabilitation needs than those with insurance. Consequently, an in-depth evaluation of medical insurance is required. The respondents who reported more than three health problems were also perceived as having more unmet medical rehabilitation needs than healthier individuals, contrary to the findings of a previous study 5 . Older adults showed a low willingness to pay for a home-based rehabilitation service. Economic status and health conditions are the significant influencing factors of willingness to pay. The presence of diabetes or tumors positively influenced willingness to pay. Still, the reason for the difference remains unclear and needs to be further investigated. People without disabilities are thought to require fewer rehabilitation services from their caregivers than those with physical or cognitive disabilities 13 . The present study found that age and disability status influenced the possibility of reporting unmet rehabilitation service needs. The respondents aged ≥ 60 years were significantly more likely than the younger respondents to report unmet needs for auxiliary equipment (P < 0.001). Policymakers and healthcare professionals should adjust their efforts to ensure to meet the rehabilitation service needs of the older adults in the community. These findings are consistent with the results of Kołłątaj et al. 12 ; nonetheless, they are still limited in Mainland China and have a limited application to individuals with disabilities 5 .
Some previous studies found correlations between educational attainment and rehabilitation service needs [37][38][39] . However, our results did not show any impact of education on unmet rehabilitation service needs; thus, further studies are needed to clarify the relationship.
The findings of the present study can assist in raising public awareness and education initiatives in the Rehabilitation Medicine Department of Chengfei Hospital and community health centers. This study may further the integration and guidance of management departments responsible for community rehabilitation resources. Moreover, it may further the efforts to increase medical insurance coverage and rehabilitation service projects, as well as improve facilities for people with disabilities.
Based on the obtained results, we would like to propose several public health recommendations: firstly, the government should establish rehabilitation quality control centers in the three-tier health system, secondary hospitals, and rehabilitation institutions, emphasizing the necessity to meet the needs of married people, those with low income, and the uninsured population in the community. Secondly, this study might serve as a valuable reference for the Community-Based Rehabilitation Committee of the Chengdu Society of Rehabilitation Medicine (a folk medicine organization) for its work in community rehabilitation. Thirdly, the reported data highlight the vulnerabilities of uninsured people, encouraging Chengdu Human Resource and Social Security Bureau to address these concerns.
Despite the aforementioned contributions, the current study has several limitations. First, the sample was not representative, considering the sampling was randomized in the three Qingyang District communities. The demographics of this city's middle-aged and older population require further investigation. Nonetheless, this kind of community differentiation was used in previous studies 32 . Future studies should address these two demographic design flaws to provide a complete idea of the rehabilitation needs of older adults in Chengdu. Second, we examined fewer rehabilitation service types compared to previous studies in developed countries 40,41 . For example, we did not test unmet needs for physical therapy, occupational therapy, physiotherapy, traditional or basic rehabilitation, speech, swallowing, or psychological rehabilitation. Third, some social and financial factors were not tested. For example, a previous study in Nepal found that mountain geography, poor road infrastructure, and inconveniences influenced access to community rehabilitation services 42 . All our respondents were residents of urban Chengdu, located on the Chengdu Plain, where the altitude varies by no more than five meters. However, additional social and financial factors should be analyzed. Fourth, the rehabilitation service project implementers might have biased the research results 43 , which we did not control in this study. Finally, using established questions to assess rehabilitation service needs provides only general information. Future studies employing qualitative methods to understand better the needs for rehabilitation services and individual expectations for rehabilitation are required.
However, although similar studies have used different methods in other populations 44 , we administered questionnaires in person, considering that such an approach has been identified as the optimal approach in epidemiological research 45 .

Conclusion
This study found that > 75% of residents had unmet needs for rehabilitation, including medical rehabilitation, daily care, social participation, and recreational therapeutic activities, while < 30% were in need of auxiliary equipment. Marital status, financial factors, and medical insurance affected the respondents' rehabilitation service needs. Rehabilitation programs should target these vulnerable groups and acknowledge that the lack of auxiliary equipment for older adults and individuals with disabilities is a major problem in current rehabilitation efforts. www.nature.com/scientificreports/

Data availability
All data generated or analyzed during this study are included in this published article.